Non-antibiotic prevention strategies for recurrent urinary tract infections in women: A systematic review

Recurrent urinary tract infections (rUTIs) in women represent a frequent and burdensome clinical problem, often leading to repeated antimicrobial exposure, reduced quality of life, and increased healthcare utilization. Although antibiotic prophylaxis can reduce recurrence, long-term or repeated antibiotic use contributes to adverse effects, disruption of the urogenital microbiota, and antimicrobial resistance. This systematic review summarizes current evidence on non-antibiotic prevention strategies for rUTIs in adult women, with emphasis on methenamine hippurate, vaginal estrogen, cranberry products, D-mannose, probiotics, increased fluid intake, immunoprophylaxis, and intravesical glycosaminoglycan therapies. A structured literature search was performed in PubMed/MEDLINE and PubMed Central for studies and reviews published up to September 2026. Relevant randomized trials, systematic reviews, meta-analyses, clinical reviews, and guideline documents were included. The strongest contemporary evidence supports methenamine hippurate as an antibiotic-sparing alternative in selected women, vaginal estrogen in peri- and postmenopausal women, cranberry products as an option with modest benefit, and increased water intake in women with low baseline fluid intake. Evidence for D-mannose and probiotics is inconsistent, while immunoprophylaxis and intravesical therapies remain promising but require further standardization. Non-antibiotic prevention should be individualized according to menopausal status, recurrence pattern, comorbidities, preferences, and local antimicrobial stewardship priorities.